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Coroner criticises care home after man choked to death on marshmallow


A coroner has criticised a care home over its "significant management failure" after a mentally disabled patient choked to death on a marshmallow.

Patrick Casey, 41, from Birmingham, died on April 5 2019 at Barnet Hospital after being found unresponsive at Devon House care home, north London, the inquest was told.

Mr Casey had been fed marshmallows by care workers, despite being on a strict pureed diet, the inquest at North London Coroner's Court heard.

On the day of Mr Casey's death, the inquest heard there was one agency nurse on duty, who had never worked at the care home before, and did not undergo induction training.

The inquest heard support workers found Mr Casey in his room limp in his wheelchair with marshmallow "dripping from his mouth" and in his hand, and an opened bag of marshmallows within his reach.

Mr Casey had been a resident at the Priory Group care home since 2014 and used a wheelchair after suffering a serious brain injury when a car struck him in 2005.

The court heard Mr Casey would not have been able to open the bag of sweets himself.

During the inquest, serice manager at Devon House, Claire Twyford, told the inquest that she was unaware  that Mr Casey was being fed marshmallows "cut up in small pieces" by care staff until after he had died.

Ms Twyford said she had not been at the care home during this incident and that Mr Casey's family had not raised concerns about him choking to her, adding that, if they had, she would have acted on them "as soon as reasonably possible.”

When asked what she would have done had she seen marshmallows in Mr Casey's room, Ms Twyford said: "I would have removed them. I would've asked the staff why they were there and made sure there was communication not to have them."

Ms Twyford said she had been on secondment at another care home in High Wycombe for most of 2019 and agreed that during that time there was confusion about the chain of command.

The inquest heard care workers who found Mr Casey unresponsive waited for permission from the nurse before administering first aid, which Ms Twyford said was a misunderstanding among staff.

Activity co-ordinator, Eleanor Powell, told the inquest she would buy marshmallows for Mr Casey to eat as it was "already a general culture when I arrived there.”

The medical cause of death was given as choking, aspiration  - inhaling food into airways - and acquired brain injury.

Senior coroner, Andrew Walker, stressed the importance of care homes needing to have someone responsible for ensuring a patient's medical and care plan needs are met.

He said: "The registered manager in this case was completely unaware that staff were providing to Mr Casey foodstuff that was potentially fatal to him. The general understanding by care staff was Mr Casey could be given marshmallows cut into pieces.

"This view was formed without any professional input by a speech and language assessment."

He said staff at Devon House care home, which has since closed, had a "limited and flawed" understanding regarding Mr Casey's food,  which was not corrected or checked at management level.

Giving a narrative conclusion, Mr Walker said Mr Casey died after choking on food following a failure to follow the dietary requirements.

Mr Casey's sister, Mary Casey, said: "Following the coroner's conclusion we hope that changes are made urgently to prevent similar tragedies.